Trends in Extended-Duration Venous Thromboembolism Prophylaxis Following Radical Cystectomy

Prophylactic heparin does not increase clinically significant bleeding following transurethral resection of a bladder tumor

INTRODUCTION

Transurethral resection of bladder tumor (TURBT) is a high bleeding risk procedure due to resection over a mucosal surface and is often performed in patients with risk factors for venous thromboembolism (VTE). Limited data exist to inform the risks and benefits of prophylactic heparin before TURBT. We sought to assess whether preoperative heparin was associated with clinically significant bleeding after TURBT.

METHODS

We retrospectively identified 583 consecutive patients who underwent TURBT between Jan 1, 2021 and April 30, 2023. In April 2022 we began routinely administering 5,000 units of subcutaneous heparin at anesthesia induction during TURBT. The primary outcome was clinically significant bleeding within 30 days of TURBT, defined as reoperation for clot evacuation/fulguration, clot retention, blood transfusion, and/or continuous bladder irrigation.

RESULTS

Among 583 patients, 220 (38%) received preoperative heparin and 363 (62%) did not. Twenty-five patients experienced a bleeding event, including 6 (2.7%) in the heparin group and 19 (5.2%) in the no heparin group (P = 0.25). After adjusting for sex and tumor size, heparin was not significantly associated with clinically significant bleeding (adjOR 0.51, 95% CI, 0.18-1.2, P = 0.16). Three patients (0.5%) experienced a 30-day VTE, including 1 (0.5%) in the heparin group and 2 (0.6%) in the group without heparin (P = 0.9).

CONCLUSION

We did not observe a statistically significant difference in the rate of clinically significant bleeding within 30 days of TURBT between patients treated with and without preoperative heparin, suggesting that preoperative heparin can be considered among patients at high risk of postoperative VTE.

Comparison of Apixaban Versus Enoxaparin for Venous Thromboembolism Prevention After Radical Cystectomy: The CARE Trial

CARE is a pragmatic randomized clinical trial designed to compare adherence, satisfaction, patient out-of-pocket costs, and venous thromboembolism (VTE) rates between apixaban and enoxaparin prescribed as VTE prophylaxis on discharge after radical cystectomy.

Direct Oral Anticoagulants for Venous Thromboembolism Prophylaxis Following Robot-assisted Radical Cystectomy: A Retrospective Feasibility Study at a Single Academic Medical Center

OBJECTIVES

To evaluate the use of direct oral anticoagulants following radical cystectomy for venous thromboembolism prophylaxis. We compared the experience of those who received venous thromboembolism prophylaxis following a robot-assisted radical cystectomy with either a direct oral anticoagulant or enoxaparin.

METHODS

Medical records of 66 patients who underwent robot-assisted radical cystectomy between July 2017 and May 2020 at a single academic institution were reviewed retrospectively. Patients received extended prophylaxis with either a direct oral anticoagulant or enoxaparin before or following surgical discharge. Venous thromboembolic events and complications resulting in emergency department visits and readmissions were reviewed over a 90-day postoperative period.

RESULTS

A total of 4 venous thromboembolic events within 90 days of surgery were observed. Among patients taking enoxaparin, 5% (2/37) developed a deep vein thrombosis and 3% (1/37) developed a pulmonary embolism. Among patients taking direct oral anticoagulants, 3% (1/29) developed a deep vein thrombosis. Zero patients in the enoxaparin group and 3% (1/29) of patients in the direct oral anticoagulant group experienced bleeding that required an emergency department visit.

CONCLUSION

Direct oral anticoagulants performed comparably to enoxaparin in this feasibility study following robot-assisted radical cystectomy in 66 patients. No significant differences in the number of venous thromboembolisms or bleeding complications were observed. These data encourage future studies and support the prospect of direct oral anticoagulants as a potentially suitable oral alternative to injectable low molecular weight heparins for venous thromboembolism prophylaxis following radical cystectomy.

Initial Experience with Apixaban for Extended Venous Thromboembolism Prophylaxis After Radical Cystectomy

Patients who undergo radical cystectomy (RC) are at elevated risk of venous thromboembolism and associated morbidity and mortality. Guidelines recommend extended thromboprophylaxis (ETP), typically with heparins, but adherence is low. Outside urology, low-dose apixaban has been used for postoperative ETP with success. We describe our first experiences with low-dose apixaban for ETP after RC for bladder cancer. In our sample of 72 patients who underwent RC for cancer and subsequently received apixaban 2.5 mg twice daily for ETP, there were no symptomatic thromboembolic events and no major bleeding events. Other complication rates were in line with historical reports. Our experience with apixaban 2.5 mg twice daily for ETP after RC demonstrates safety and potential efficacy. A transition from injectable to oral thromboprophylaxis has the potential to improve adherence and patient satisfaction, while allowing the possibility of further extending prophylaxis beyond 28 d, which may be beneficial in selected patients. Further evaluation of apixaban for thromboprophylaxis in urologic cancer surgery is warranted. PATIENT SUMMARY: Home injectable heparin is used for 4 weeks after bladder removal surgery to prevent blood clots. We evaluated our use of the oral medication apixaban for prevention of blood clots after bladder removal surgery and found that none of our patients had major bleeding events or symptomatic blood clots. We conclude that there should be further evaluation of the use of oral instead of injectable medication to prevent blood clots after urology surgery.

Practice patterns for extended venous thromboembolism chemoprophylaxis among urologic oncologists after radical cystectomy

INTRODUCTION

Extended outpatient chemoprophylaxis (ECP) following radical cystectomy (RC) for bladder cancer is proven to reduce rates of venous thromboembolism (VTE). While ECP is commonly performed with enoxaparin, its cost-effectiveness and adherence rate has been called into question. Data from orthopedic literature suggest that ECP with direct oral anticoagulants (DOACs) may be as effective in VTE prevention as enoxaparin in patients undergoing joint surgery. Our goal is to determine how urologic oncologists employ ECP following RC.

METHODS

Members of the Society of Urologic Oncology were surveyed on practice patterns for the use of ECP after RC. Specific questions were asked regarding the use of inpatient and outpatient VTE prophylaxis, as well as perceived barriers to DOACs and enoxaparin.

RESULTS

There were 121 of 878 (13.8%) respondents and the majority were in academic practices (83%). Most respondents had at least 5 years of experience and performed greater than 10 cystectomies annually. Almost all participants utilized inpatient (97%) and extended (80%) chemoprophylaxis for VTE prevention. Of those who elected for ECP, almost all (96%) used enoxaparin. Only 3 respondents (3%) prescribed oral agents such as rivaroxaban (2) or warfarin (1). Among those using enoxaparin, financial-specific barriers to treatment such as lack of insurance coverage (38%), inability to afford the medication (51%), and need for additional insurance authorization (44%) were reported. Poor patient adherence and refusal to perform injections were reported by 20% and 18% of respondents, respectively. Among the 23 physicians who did not use ECP, cost (39%) and delivery method (26%) were cited as barriers to treatment.

CONCLUSIONS

The majority of surveyed urologic oncologists are prescribing subcutaneous enoxaparin ECP following RC. Poor patient adherence due to self-injections and financial barriers were frequently reported and represent a possible opportunity for the use of oral anticoagulants in the post-operative setting. These data will be used in the development of a proposed clinical trial of a DOAC in the post-RC setting.